Utilization Review Nurse Part Time Remote

Job Description

The utilization review nurse plays a critical role in enhancing the quality, completeness, and accuracy of clinical documentation. This involves extensive collaboration with physicians, nursing staff, case managers, patient caregivers, and Health Information Management coding staff to ensure clinical documentation accurately reflects treatment decisions, diagnoses, and levels of service rendered. Responsibilities: • Perform admission, concurrent, and retrospective medical reviews to provide reimbursement information to payers. • Act as liaison between hospital departments, medical staff, and payers on issues related to medical necessity for admission and continued stay. • Maintain open communication with physician advisors. • Provide UM education to clinical staff as needed. • Apply standardized criteria and guidelines to determine appropriateness of admissions and assignment of patient class (observation, inpatient, outpatient). • Monitor wasted resources while maintaining high-quality care. • Ensure compliance with Medicare and Medicaid regulations. • Support Care Management department regarding utilization, insurance, and payer issues. • Identify potential problems with payment eligibility and recommend corrective action. • Participate in UR meetings. Qualifications: • Education: BSN required. • Experience: Minimum 3 years of pediatric clinical experience required. • KSAs: Required upon hire or transfer. • Preferred Education & Experience: Previous UR, case management, or care coordination experience preferred. License and/or Certification: • Required: RN license. • Preferred: ACM certification. Knowledge, Skills, and Abilities: • Pathophysiology and Disease Process knowledge. • Working knowledge of clinical information. • High degree of familiarity with clinical care to establish credibility with physicians, LIPs, nurses, and other members of the front-line care team. • Ability to provide clinical and financial education to colleagues, patients, and families. • Strong interpersonal and communication skills to manage competing priorities of different stakeholders. • Electronic medical record expertise. Ability to: • Learn/develop skills necessary to perform Clinical Documentation review of medical records. • Handle multiple priorities and increasing responsibility. • Collaborate with others to achieve common goals through mutual cooperation. • Influence others for positive and productive outcomes. • Quickly process complex problems, identify key components, and develop plans for resolution. • Learn and use multiple computer systems. Apply Job!